When you check into a hospital for a procedure, you count on the fact that certain no-brainer things will be handled appropriately so that the surgery itself will go off without a hitch. The right body part will be operated on. Equipment won’t be left behind inside your body when the procedure is finished. You will receive the correct surgical procedure instead of being mixed up with the person down the hall.
These seem like things that should go without saying, but as new research suggests, mistakes of this nature occur far more regularly than patients might realize. Researchers from the Johns Hopkins University School of Medicine have published a report in the Surgery online journal which suggests 4,082 mistakes similar to what’s described above occur on an annual basis. These “never events” are things that are easily preventable but which nevertheless can severely compromise patient safety.
What’s also shocking is that, according to researchers, numerous such events never even get reported, and the patient often doesn’t receive an appropriate medical malpractice payout. Incidents in which equipment gets left behind typically only are discovered once the patient suffers some type of complication, and if no such symptoms present themselves, things like surgical sponges may never be discovered. It’s also highly likely that numerous patients might opt not to file a claim.
That’s why the researchers concluded that more than 4,000 never events occur every year even though only 9,744 such events were recorded in the 20 year time period between 1990 and 2010. These are only those incidents which resulted in some sort of medical malpractice payment, and one study estimates that only about 12% of incidents result in the patient receiving such a financial reimbursement.
Leading the list of typical never events was an object being left behind, an occurrence which accounts for nearly 50% of all incidents. Wrong procedures and wrong sites each made up about one quarter of the incidents, while wrong patient never events that resulted in a medical malpractice payment were relatively rare, only .3%.
It’s clear that hospitals must take steps to ensure that these events become increasingly uncommon. We are seeing strides made in that department though. Some hospitals have begun to institute procedures meant to cut down on error, such as placing scannable bar codes on every piece of equipment or running through a spot check before the procedure to ensure that every aspect of the operation goes smoothly and without an incident.
Yet some think the answer lies with monetary punishment. A Harvard expert on patient safety believes that a $100,000 fine levied against all institutions that are the site of a never event might be the way to go. If subsequent incidents result in even steeper fines, then hospitals might quickly see the benefit of enacting new safety procedures.
